Pro-hemostatic Therapy for Prevention and Treatment of Bleeding

Abstract

The hemostatic system is able to swiftly convert fluid blood to a solid clot when there is a disruption of vascular integrity and bleeding occurs. Simultaneously, another important feature of hemostasis is to maintain blood fluidity within the blood vessel to guarantee adequate circulation throughout the body. These two paradoxical functions of the coagulation system can only be executed when, under physiological circumstances, there is a balance between low-level ongoing basal coagulation activation and permanent anticoagulation by both physiological anticoagulant mechanisms and fibrin removal as a function of the fibrinolytic system. Pharmacological agents may interfere in this balance, for example by inhibiting coagulant activity or promoting anticoagulant mechanisms, and indeed this type of treatment has proven to be effective in the prevention and treatment of thrombotic disease. Similarly, other agents are capable of promoting hemostasis or fibrin formation, or can block fibrinolytic activity. These so-called ‘pro-hemostatic agents’ may be useful in the prevention and treatment of bleeding in patients with coagulation defects, but also in patients with an a priori normal coagulation system, who experience severe (post-operative) bleeding or are to undergo procedures known to be associated with major blood loss [1]. In this chapter, we will discuss the aims and potential risks of pro-hemostatic therapy, the various agents with a pro-hemostatic potential and the efficacy of pro-hemostatic drugs to reduce perioperative blood loss or treat excessive (postoperative) bleeding.